Procedures - Bony Thorax (Unit 2-3)

What bones comprise the bony thorax?

• Sternum

• 12 Thoracic Vertebrae

• 12 Pairs or Ribs

• Clavicle

• Scapula

The 4 segments of the sternal body may not be fully united until the age of:

25

The xiphoid tip of the sternum may not be completely ossified until the age of:

40

Ribs 1-7 are considered:

True ribs

Ribs 1-7 connect to the _________ via cartilage called _________.

• Sternum

• Costal cartilage

The sternum has 7 pairs of _________ located laterally along the _____________ & _______________.

• Facets

• Manubrium

• Body

Ribs 8-12 are considered:

False ribs

Ribs 8-10 have costocartilage and join together at the costocartilage of rib ____.

7

Ribs 11 and 12 are considered:

Floating ribs

The posterior end of the rib (also referred to as the __________) articulates with the:

• Vertebral End

• Thoracic Verebrae

The anterior end (_________) of the rib articulates with the:

• Sternal End

• Costal Cartilage

The area of the rib which protects an artery, vein, and nerve is called:

Costal Groove

The bony thorax is typically widest at ribs:

8th or 9th ribs

Jugular notch can also be called:

Suprasternal Notch or Manubrial Notch

Jugular Notch: Vertebral Lvl

T2/3

Sternal Angle: Vertebral Lvl

T4/5

Xiphoid Process: Vertebral Lvl

T9/10

Inferior Rib Angle/ Interior Costal Margin: Vertebral Lvl

L2/3

The clavicles articulate with the _____________ of the sternum at the clavicular _________.

• Manubrium

• Notch

Rather than a true AP or PA projections, the patient is placed in this position to shift the sternum left of the thoracic vertebrae:

• Hyposthenic or thin patients require more/less rotation.

• Barrel chested patient requires more/less rotation.

• 15-20 degree RAO position

• More

• Less

Why would a PA projection be preferred over an AP for sternoclavicular joints?

Least amount of magnification distortion and reduces the amount of radiation to the thyroid.

• AP is easier to palpate

The only articulation between the thorax and the upper extremity is the:

Sternoclavicular Joints (SC)

What are two other names for the body of the sternum?

Corpus or Gladiolus

What position is best for visualizing axillary ribs?

Oblique

List criteria needed for for x-raying ribs below the diaphragm:

• Lower rib pain

• Recumbent

• On Expiration

• Medium kVp

List criteria needed for for x-raying ribs above the diaphragm:

• Upper rib pain

• Erect

• On Inspiration

• Lower kVp

If your patient is having left rib pain (unspecified as anterior or posterior), which two obliques may be acquired?

RAO or LPO

What is the routine exam for a 2V sternum?

RAO and Lateral

How does the positioning for an oblique sternum change based on body habitus?

Patients with a thin chest will need more rotation than patients with a large thorax.

For a PA CXR, ___________ ribs are more magnified.

Posterior

For an AP CXR, ____________ ribs are more magnified.

Anterior

List the best breathing techniques for:

• Lateral Sternum

• Oblique Sternum

• Above Diaphragm Ribs

• Below Diaphragm Ribs

• PA SC Joints

• Anterior Obliques SC Joints

• Inspiration

• Orthostatic

• Inspiration

• Expiration

• Expiration

• Expiration

Which ribs are considered ‘true ribs’?

1-7

Which ribs are considered ‘floating’?

11 and 12

Label

1. Clavicle

2. Sternoclavicular Joint

3. Manubrium

4. Sternal Angle

5. Body

6. Xiphoid Process

List two additional terms to refer to the body of the sternum:

Corpus or Gladiolus

The only articulation between the bony thorax and the upper extremity is/are the:

Sternoclavicular Joint

Segments of the sternum may not fully fuse until _____ yr old.

25

RAO Sternum

• ________ degree oblique

  • This will shift the sternum to the right/left of the thoracic vertebrae.

• Rotate hyposthenic patients more/less.

• Rotate hypersthenic patients more/less.

• 15-20

• Left

• More

• Less

The ‘axillary’ portion of ribs refers to this:

• Which projections are best for visualization?

• The area under the arm; curvature of the ribs

• Oblique

Anterior Pain

• PA/AP projection

• Posterior/Anterior Obliques

• PA

• Anterior

Posterior Pain

• PA/AP projection

• Posterior/Anterior Obliques

• AP

• Posterior

Breathing

• Above the diaphragm:

• Below the diaphragm:

• Inspiration

• Expiration

Label

1. Clavicle

2. Sternoclavicular Joint

3. Manubrium

4. Body of Sternum

Label

1. Shaft

2. Angle

3. Tubercle

4. Neck

5. Head

Label

1. Right SC Joint

2. Right Clavicle

3. Manubrium

4. Left SC Joint

5. Left Clavicle

Why an RAO over a PA or AP projection for the Sternum?

The oblique view is performed so the sternum is projected over the heart, which provides a homogenous density. Avoids superimposition of the spine.

What is the SID for all bony thorax imaging?

40”

Sternum CR

Center of sternum

• Midway between jugular notch and xiphoid tip

Image Criteria: RAO Sternum

• Sternum is visualized, superimposed on heart shadow

• Shifts sternum to the left of the thoracic vertebrae

Image Criteria: Lateral Sternum

• Entire sternum with minimal overlap of soft tissues

What is the routine for SC joints?

PA and Anterior Obliques (Both RAO and LAO)

SC Joints PA CR

MSP at lvl of T2-3

SC Joints Anterior Obliques CR

1-2” toward the upside from MSP @ lvl of T2-3

• Rotate pt 10-15 degree for each oblique

Image Criteria: PA SC Joints

• Bilateral SC Joints (for comparison)

• Lateral aspect of manubrium

• Medial portion of the clavicles visualized lateral to vertebral column through superimposing ribs and lungs

SC Joints: Anterior Obliques. Which joint is best visualized?

Downside SC joint is best visualized

• RAO = right SC joint

• LAO = left SC joint

Image Criteria: SC Joints Anterior Obliques

• Both obliques are done for comparison

• Manubrium

• Medial portion of clavicles

• Downside SC joint is best demoed

• SC joint on the upside will be foreshortened

Rib Routine

• Minimum of 2 projections that will:

  • Place the area of interest closest to the IR

  • Rotates the spine away from the area of interest

• Possible CXR

Why is obtaining a patient hx for ribs exams required?

The patient’s hx will indicate what projections and positions must be performed.

• Obtain the location of rib pain/injury

Which Rib Oblique: Right Anterior Pain

LAO

Which Rib Oblique: Left Anterior Pain

RAO

Which Rib Oblique: Right Posterior Pain

RPO

Which Rib Oblique: Left Posterior Pain

LPO

Rib Obliques

• Anterior Pain

  • RAO or LAO

  • Affected side away from IR

• Posterior Pain

  • RPO and LPO

  • Affected side is closest to IR

If your paitent is having right rib pain (unspecified as anterior or posterior), which two obliques may be acquired?

RPO and LAO

Unilateral vs Bilateral RIbs

Unilateral

• One sided pain only

• May be able to fit all ribs on 1 lengthwise IR

• Radiation dose minimized

Bilateral

• For comparision

• May catch referred pain on other side

• Preferred for trauma